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| NOTICE of PRIVACY PRACTICES |
We care about our patients’ privacy and strive to protect the confidentiality of your
medical information at this practice. New federal legislation requires that we issue
this official notice of our privacy practices. You have the right to the confidentiality of
your medical information, and this practice is required by law to maintain the privacy of
that protected health information. This practice is required to abide by the terms of the
Notice of Privacy Practices currently in effect, and to provide notice of its legal duties
and privacy practices with respect to protected health information. If you have any
questions about this Notice, please contact the Privacy Officer at this practice.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record,
all employees, staff, and other personnel at this practice who may need access to your
information must abide by this Notice. All subsidiaries, business associates (e.g. a
billing service), sites, and locations of this practice may share medical information with
each other for treatment, payment purposes, or health care operations described in
this Notice. Except where treatment is involved, only the minimum necessary
information needed to accomplish the task will be shared.
How We May Use and Disclose Medical Information about You
The following categories describe different ways that we may use and disclose
medical information without your specific consent or authorization. Examples are
provided for each category of uses or disclosures. Not every possible use or
disclosure in a category is listed.
For Treatment We may use medical information about you to provide you with medical
treatment or services. Example: In treating you for a specific condition, we may need
to know if you have allergies that could influence which medications we prescribe for
the treatment process.
For Payment We may use and disclose medical information about you so that the
treatment and services you receive from us may be billed and payment may be
collected from you, an insurance company, or a third party. Example: We may need to
send your protected health information, such as your name, address, office visit date,
and codes identifying your diagnosis and treatment to your insurance company for
payment.
For Health Care Operations We may use and disclose medical information about you
for health care operations to assure that you receive quality care. Example: We may
use medical information to review our treatment and services and evaluate the
performance of our staff in caring for you.
Other Uses or Disclosures That Can Be Made Without Consent or Authorization
We may contact you to provide appointment reminders or information about treatment
alternatives or other health related information.
Uses and Disclosures of Protected Health Information Requiring Your Written
Authorization
Other uses and disclosures of medical information not covered by this Notice or the
laws that apply to us will be made only with your written authorization. If you give us
authorization to use or disclose medical information about you, you may revoke that
authorization, in writing, at any time. If you revoke your authorization, we will thereafter
no longer use or disclose medical information about you for the reasons covered by
your written authorization, and that we are required to retain our records of the care we
have provided you.
Your Individual Rights Regarding Your Medical Information
Complaints If you believe your privacy rights have been violated, you may file a
complaint with the Privacy Officer at this practice or with the Secretary of the
Department of Health and Human Services. All complaints must be submitted in
writing. You will not be penalized or discriminated against for filing a complaint.
Right to Request Restrictions You have the right to request a restriction or limitation
on the medical information we use or disclose about you for treatment, payment, or
health care operations or to someone who is involved in your care or the payment for
your care. We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you with emergency
treatment. To request restrictions, you must submit your request in writing to the
Privacy Officer at this practice. In your request, you must tell us what information you
want to limit.
Right to Inspect and Copy You have the right to inspect and copy medical information
that may be used to make decisions about your care. Usually, this includes medical
and billing records but does not include psychotherapy notes, information compiled for
use in a civil, criminal, or administrative action or proceeding, and protected health
information to which access is prohibited by law. To inspect and copy medical
information that may be used to make decisions about you, you must submit your
request in writing to the Privacy Office at this practice. If you request a copy of the
information, we reserve the right to charge a fee for the costs of copying, mailing, or
other supplies associated with your request. We may deny your request to inspect and
copy in certain very limited circumstances. If you are denied access to medical
information, you may request that the denial be reviewed. Another licensed health care
professional chosen by this practice will review your request and the denial. The
person conducting the review will not be the person who denied your request. We will
comply with the outcome of the review.
Right to Amend If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request
an amendment for as long as the information is kept. To request an amendment, your
request must be made in writing and submitted to the Privacy Officer at this practice. In
addition, you must provide a reason that supports your request. We may deny your
request for an amendment if it is not in writing or does not include a reason to support
the request. In addition, we may deny your request if the information was not created
by us, is not part of the medical information kept at this practice, is not part of the
information which you would be permitted to inspect and copy, or which we deem to be
accurate and complete. If we deny your request for amendment, you have the right to
file a statement of disagreement with us. We may prepare a rebuttal to your statement
and will provide you with a copy of any such rebuttal. Statements of disagreement and
any corresponding rebuttals will be kept on file and sent out with any future authorized
requests for information pertaining to the appropriate portion of your record.
Right to an Accounting of Non-Standard Disclosures You have the right to request a
list of the disclosures we made of medical information about you. To request this list,
you must submit your request to the Privacy Officer at this practice. Your request must
state the time period for which you want to receive a list of disclosures that is no longer
than six years, and may not include dates before April 14, 2003. Your request should
indicate in what form you want the list (example: on paper or electronically). The first
list you request within a 12-month period will be free. For additional lists, we reserve
the right to charge you for the cost of providing the list.
Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice
at any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy. To obtain a paper copy of the current Notice, please request
one in writing from the Privacy Officer at this practice.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or
changed Notice effective for medical information we have already created.
medical information at this practice. New federal legislation requires that we issue
this official notice of our privacy practices. You have the right to the confidentiality of
your medical information, and this practice is required by law to maintain the privacy of
that protected health information. This practice is required to abide by the terms of the
Notice of Privacy Practices currently in effect, and to provide notice of its legal duties
and privacy practices with respect to protected health information. If you have any
questions about this Notice, please contact the Privacy Officer at this practice.
Who Will Follow This Notice
Any health care professional authorized to enter information into your medical record,
all employees, staff, and other personnel at this practice who may need access to your
information must abide by this Notice. All subsidiaries, business associates (e.g. a
billing service), sites, and locations of this practice may share medical information with
each other for treatment, payment purposes, or health care operations described in
this Notice. Except where treatment is involved, only the minimum necessary
information needed to accomplish the task will be shared.
How We May Use and Disclose Medical Information about You
The following categories describe different ways that we may use and disclose
medical information without your specific consent or authorization. Examples are
provided for each category of uses or disclosures. Not every possible use or
disclosure in a category is listed.
For Treatment We may use medical information about you to provide you with medical
treatment or services. Example: In treating you for a specific condition, we may need
to know if you have allergies that could influence which medications we prescribe for
the treatment process.
For Payment We may use and disclose medical information about you so that the
treatment and services you receive from us may be billed and payment may be
collected from you, an insurance company, or a third party. Example: We may need to
send your protected health information, such as your name, address, office visit date,
and codes identifying your diagnosis and treatment to your insurance company for
payment.
For Health Care Operations We may use and disclose medical information about you
for health care operations to assure that you receive quality care. Example: We may
use medical information to review our treatment and services and evaluate the
performance of our staff in caring for you.
Other Uses or Disclosures That Can Be Made Without Consent or Authorization
- As required during an investigation by law enforcement agencies
- To avert a serious threat to public health or safety
- As required by military command authorities for their medical record
- To workers’ compensation or similar programs for processing of claims
- In response to a legal proceeding
- To a coroner or medical examiner for identification of a body
- If an inmate, to the correctional institution or law enforcement official
- As required by the US Food and Drug Administration (FDA)
- Other healthcare providers’ treatment activities
- Other covered entities’ and providers’ payment activities
- Other covered entities’ healthcare operations activities (to the extent permitted
under HIPAA) - Uses and disclosures required by law
- Uses and disclosures in domestic violence or neglect situations
- Health oversight activities
- Other public health activities
We may contact you to provide appointment reminders or information about treatment
alternatives or other health related information.
Uses and Disclosures of Protected Health Information Requiring Your Written
Authorization
Other uses and disclosures of medical information not covered by this Notice or the
laws that apply to us will be made only with your written authorization. If you give us
authorization to use or disclose medical information about you, you may revoke that
authorization, in writing, at any time. If you revoke your authorization, we will thereafter
no longer use or disclose medical information about you for the reasons covered by
your written authorization, and that we are required to retain our records of the care we
have provided you.
Your Individual Rights Regarding Your Medical Information
Complaints If you believe your privacy rights have been violated, you may file a
complaint with the Privacy Officer at this practice or with the Secretary of the
Department of Health and Human Services. All complaints must be submitted in
writing. You will not be penalized or discriminated against for filing a complaint.
Right to Request Restrictions You have the right to request a restriction or limitation
on the medical information we use or disclose about you for treatment, payment, or
health care operations or to someone who is involved in your care or the payment for
your care. We are not required to agree to your request. If we do agree, we will comply
with your request unless the information is needed to provide you with emergency
treatment. To request restrictions, you must submit your request in writing to the
Privacy Officer at this practice. In your request, you must tell us what information you
want to limit.
Right to Inspect and Copy You have the right to inspect and copy medical information
that may be used to make decisions about your care. Usually, this includes medical
and billing records but does not include psychotherapy notes, information compiled for
use in a civil, criminal, or administrative action or proceeding, and protected health
information to which access is prohibited by law. To inspect and copy medical
information that may be used to make decisions about you, you must submit your
request in writing to the Privacy Office at this practice. If you request a copy of the
information, we reserve the right to charge a fee for the costs of copying, mailing, or
other supplies associated with your request. We may deny your request to inspect and
copy in certain very limited circumstances. If you are denied access to medical
information, you may request that the denial be reviewed. Another licensed health care
professional chosen by this practice will review your request and the denial. The
person conducting the review will not be the person who denied your request. We will
comply with the outcome of the review.
Right to Amend If you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right to request
an amendment for as long as the information is kept. To request an amendment, your
request must be made in writing and submitted to the Privacy Officer at this practice. In
addition, you must provide a reason that supports your request. We may deny your
request for an amendment if it is not in writing or does not include a reason to support
the request. In addition, we may deny your request if the information was not created
by us, is not part of the medical information kept at this practice, is not part of the
information which you would be permitted to inspect and copy, or which we deem to be
accurate and complete. If we deny your request for amendment, you have the right to
file a statement of disagreement with us. We may prepare a rebuttal to your statement
and will provide you with a copy of any such rebuttal. Statements of disagreement and
any corresponding rebuttals will be kept on file and sent out with any future authorized
requests for information pertaining to the appropriate portion of your record.
Right to an Accounting of Non-Standard Disclosures You have the right to request a
list of the disclosures we made of medical information about you. To request this list,
you must submit your request to the Privacy Officer at this practice. Your request must
state the time period for which you want to receive a list of disclosures that is no longer
than six years, and may not include dates before April 14, 2003. Your request should
indicate in what form you want the list (example: on paper or electronically). The first
list you request within a 12-month period will be free. For additional lists, we reserve
the right to charge you for the cost of providing the list.
Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice
at any time. Even if you have agreed to receive this notice electronically, you are still
entitled to a paper copy. To obtain a paper copy of the current Notice, please request
one in writing from the Privacy Officer at this practice.
Changes to This Notice
We reserve the right to change this Notice. We reserve the right to make the revised or
changed Notice effective for medical information we have already created.
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| This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. |